ANCHOR BAY SCHOOL DISTRICT 5201 County Line Road, Suite 100 Casco, Michigan Phone: , Fax:

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1 ANCHOR BAY SCHOOL DISTRICT 5201 County Line Road, Suite 100 Casco, Michigan Phone: , Fax: Anchor Bay Website: Elementary Registration Checklist My child will be attending: Ashley Elementary, Ashley Street, New Baltimore, MI, Phone: Dean A. Naldrett Elementary, Sugarbush, New Baltimore, MI, Phone: Great Oaks Elementary, Mile Road, Chesterfield, MI, Phone: Lighthouse Elementary, Washington, New Baltimore, MI, Phone: Lottie M. Schmidt Elementary, Hooker, New Baltimore, MI, Phone: Maconce Elementary, 6300 Church Road, Ira, MI, Phone: Sugarbush Elementary, Sugarbush, New Baltimore, MI, Phone: MacDonald Early Childhood Center, 5201 County Line Rd., Casco, MI Phone: Your child is not officially registered for school until all the items below have been submitted. Required information: STUDENT ENROLLMENT FORM PERMISSION TO RELEASE OFFICIAL RECORDS AFFIRMATION OF PRIOR DISCIPLINE RECORD ORIGINAL BIRTH CERTIFICATE IMMUNIZATION RECORDS PARENT/GUARDIAN PHOTO IDENTIFICATION PROOF OF RESIDENCY (2) HOME LANGUAGE SURVEY REPORT CARD AND/OR TRANSCRIPT UNDERSTANDING CONCUSSION HEARING AND VISION SCREENING (Kindergarten only) Also included: Birth certificate requirements Transportation information Required childhood immunizations Alternate bus form Statement of Varicella Food Service information Non-owner residency affidavit

2 Student Information ANCHOR BAY SCHOOL DISTRICT ENROLLMENT FORM School Grade Entering If Kindergarten: NOTE: Half Day Kindergarten will be Student s Full Legal Name (as shown on Birth Certificate) All Day ½ day held at one elementary bldg. only Last Name First Name Middle Name Primary Phone Birth Date Birth City & State (if born in US) Gender M F Secondary Phone: Street Address City State Zip Code County Rev. 12/2014 Ethnicity Is the student Hispanic/Latino? No, not Hispanic or Latino Race The question to the left is about ethnicity, not race. No matter what you selected, please answer the following by marking one or more boxes to indicate what you consider your student s race to be: Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) American Indian/Alaskan Native Black or African American White Asian American Native Hawaiian/Other Pacific Islander Students Born Outside the US Only: Country of Birth Date Entered US Date First Attended School in US (month & year) Previous School Has your child attended school in Anchor Bay before? (Include Pre-K) Yes No Previous School If Yes, School Attended Year Grade Previous District Did your child receive Special Services at Former School? Yes No If yes, check all that apply below and provide copy of plan. Special Education 504 Plan Speech/Language Title 1 Math Reading Social Work Other Services Please describe other services: Primary Household Information Student lives with: Both Parents Father/Stepmother Mother/Stepfather Father Only Mother Only Guardian Relative Foster Court Placed Divorced, Joint Custody Other: Parent/Guardian Name Relationship to Child Address Home Phone Cell Phone Employer Work Phone Parent/GuardianName Relationship to Child Address Home Phone Cell Phone Employer Work Phone Name of Parent Living Elsewhere Relationship to Child Address Address Home Phone Cell Phone Have custody papers been provided to the office? Yes No Custody Restrictions Emergency Contacts My student may be released to the following local contacts when primary contacts above cannot be reached: 1. Name Relationship to Child Primary Phone Secondary Phone 2. Name Relationship to Child Primary Phone Secondary Phone 3. Name Relationship to Child Primary Phone Secondary Phone

3 STUDENT ENROLLMENT FORM (page 2 of 2) Student Name: School Age Child Care (SACC) Does student attend Anchor Bay School Age Child Care (SACC)? Yes No If yes Before School After School Both Other: New Enrollee Transportation (If eligible, please check transportation requested) No transportation needed Both to school and home To school only Home from school only ½ Kdg. ECSE am ECSE pm Please indicate if parents have joint/shared custody and student requires transportation from both parent locations within district. Yes No If your child will be transported to the address of an assigned caregiver different from your home address, please complete the ALTERNATE BUS FORM. Other Children Who Reside in the Home Name Birth Date School/Grade Relationship to Student Name Birth Date School/Grade Relationship to Student Name Birth Date School/Grade Relationship to Student Name Birth Date School/Grade Relationship to Student Health Information If nothing known, please check Asthma Allergy Diabetes Heart Condition Seizure Hearing Problem Vision Problem List all non-food allergies List all food allergies Epi-Pen Epi-Pen Other Medical Alerts/Health Conditions Physical Limitations Medications Taken (include inhaler) Is your child required to taken medication or inhaler during the school day? Yes No If yes, Medical Form required Medical Plan: Complete a medical plan if your child has allergies/asthma/diabetes/seizures or other condition which requires treatment during the school day. Physician Name Physician Phone Preferred Hospital By signing this form below, I auhorize the physician and/ or hospital listed on this document (or any medical care facility) to treat my child in the event of serious illness or accident when I cannot be reached. Any obligation for medical expenses resulting from treatment in such a case is my responsibility and I agree to hold the school harmless. Permission to transport my child in case of emergency is also given. Information for Parents Your preschool-aged and school-aged children have certain rights or protections under the McKinney-Vento Homeless Education Assistance Act. Is your current living arrangement the result of a loss of housing or economic hardship? Yes No Unsure Your truthful and accurate answers help the district identify services that your student may be eligible to receive. Local Area Contacts: Carol Selby ext. 2342, MISD Coordinator Mary Lebioda School Release Anchor Bay School District students may be photographed or videotaped and their name and/or work displayed for educational and/or not-forprofit use in various ways: newletter articles, building videos, Channel 6 broadcasts, building video networks, athletic team rosters, club rosters, as well as, district, building and classroom web pages, etc. Students may also participate in additional learning opportunities through distance learning and virtual field trips. If you do not want your child to participate in the above activities, make your request in writing to the building principal. Verification of Information-the undersigned acknowledges that the information provided on this form is true and accurate Parent/Legal Guardian Signature Date

4 ANCHOR BAY SCHOOL DISTRICT 5201 County Line Road Casco, Michigan Phone: (586) , Fax: (586) PERMISSION TO RELEASE OFFICIAL RECORDS Student Name (as it appears on birth certificate) Birthdate Grade Entering: Previous School Name: Phone Number: Fax Number: Previous School Address Previous School City/State Zip Code The student listed above is now enrolled in Anchor Bay School District. Please mail the following school records to the school indicated below or notify us if you have no record of this student: Official cumulative record Transcript of grades and credits Achievement and ability test scores Health and/or immunization records Attendance Discipline/citizenship record Special Education Records (IEP, diagnostic reports, medical records) State of Michigan UIC number if available I hereby grant permission for the release of the above record(s) to Anchor Bay School District: Parent/Guardian Signature (Student if 18 years of age) Date Please send records to: Please send Special Educations records to: Anchor Bay Student Services 5201 County Line Road, Casco, MI Rev.8/2015

5 Rev. 3/7/2014 ANCHOR BAY SCHOOL DISTRICT STATEMENT OF PRIOR DISCIPLINE RECORD Student s Name: Previous School: Section 1 For Student and Parent A willful false statement on this affirmation will result in possible removal from Anchor Bay School District. DIRECTIONS: Please check the applicable paragraph, provide all appropriate information, and sign this document. Paragraph 1: The undersigned affirms that has NOT been suspended or expelled, or is not in the process of being suspended or expelled from any public or private school in Michigan or any other state for an offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence against persons and/or property committed on school premises, at any school sponsored activity, or on a public or private conveyance providing transportation to and from a school or school sponsored activity. Paragraph 2: The undersigned affirms that has been suspended or expelled or is in the process of being suspended or expelled from a public of private school in Michigan or another state for one or more offenses involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for an act of violence against persons and/or property committed on school premises, at any school sponsored activity, or on a public or private conveyance providing transportation to and from a school or school sponsored activity. IF YOU CHECKED PARAGRAPH 2, EXPLAIN THE CIRCUMSTANCES IN DETAIL. INCLUDE THE SCHOOL NAME, DATES OF SUSPENSION OR EXPULSION, AND A DESCRIPTION OF THE INCIDENT GIVING RISE TO THE SUSPENSION OR EXPULSION. Date Signature of Parent/Guardian (Student signature if 18 years or older) Date copy sent for verification: Initials of Anchor Bay staff member Section 2 Previous School Please check one of the statements below, sign and send back to requesting school Name of Sending (Former) School District According to our records, we can verify that the information provided above by the parent/student is correct. According to our records, the information provided above by the parent/student is not correct. If the student has been involved in offenses involving weapons, alcohol or drugs, or willful infliction of injury to persons or an act of violence against persons and/or property committed on school premises, at a school sponsored activity, or on a public or private conveyance providing transportation to or from school or a school sponsored activity, please forward appropriate disciplinary documentation. Date Phone Signature of Previous School Administrator Title

6 Anchor Bay School District Office of the Superintendent Leonard Woodside 5201 County Line Road, Suite 100 Casco, Michigan Telephone: FAX: Birth Certificate Requirements Dear Parents / Guardians, Public Act No. 84 (known as the Missing Children s Act) of the State of Michigan became effective June 27, 1987 and states that: Upon enrollment of a student for the first time in a local school district, the district shall notify, in writing, the person enrolling the student that within thirty (30) days he or she shall provide to the local school district a certified copy of the student s birth certificate or other reliable proof. Please consider this letter your notification of the law. For record-keeping purposes, your 30-day notification will begin with the first day of school. Within 30 days from that date please provide us with acceptable proof of birth for your child. If you fail to do so by the 30-day deadline, we are obligated to notify the Michigan State Police for investigation. This public act is intended to help locate missing children. Thank you in advance for your cooperation. Sincerely, Leonard Woodside Leonard Woodside Superintendent

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10 ANCHOR BAY SCHOOL DISTRICT Macomb Intermediate School District Home Language Survey The Anchor Bay School District is required by Federal and state law to collect information regarding the language background of each of its students. This information will be used by the district to determine the number of children who should be provided bilingual instruction according to Sections of the Michigan School Code of 1995, Michigan s Bilingual Education law. Name of Student: Grade: Age: Name of School Building: 1. Is your child s native tongue a language other than English? Yes No If yes, what is that language? 2. Is the primary language (the dominant language used by a person for communication) used in your child s home a language other than English? Yes No If yes, what is that language? 3. Has your student been identified or have they received Bilingual/ESL services in another district? Yes No If yes, what district? 4. *What country was your child born in? 5. *When did your child enter the United States? *Optional Parent/Guardian Signature: Date Completed:

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13 School year: ANCHOR BAY SCHOOL DISTRICT NON-OWNER RESIDENTIAL AFFIDAVIT 1. This form is to be completed if you are unable to provide proof of residency at your current address because you are not the owner or lessee of the property. 2. This form, plus 2 proofs of residency in the property owner or lessee s name, must be on file in the enrolling student s CA60 file at the school building. 3. Parent/Guardian must provide proof of residency within 30 days. Part 1: To be completed by the parent/legal guardian and signed. I do hereby certify that the information supplied concerning residency is correct. I understand that if I change addresses within the district, or move out of the district, I must immediately notify the office at my child s school. I fully understand if I falsify this statement, the child(ren) may be dropped from the Anchor Bay School District immediately. In addition, I may be responsible for paying tuition for each day the child(ren) attended Anchor Bay School District. Parent/Guardian (please print) Parent/Guardian (signature) Date: Part 2: To be completed by the resident/property owner or lessee, and signed. Resident/Property Owner or lessee must provide 2 pieces of proof of residency to support the affidavit. Proof may be a lease, utility bills, closing statement, or property tax statement. Last Name: First Name: Phone: Address: City: Zip Code: I declare that I live within the Anchor Bay School District boundaries at the above address. I further declare that the student(s) listed below and their parent(s) or legal guardian(s) are residing at my home. Student Name Date of Birth Grade School Name Resident/Property Owner Signature: Date: Rev. 2/1/2014

14 INFORMATION For Parents IF YOUR FAMILY LIVES IN ANY OF THE FOLLOWING SITUATIONS: In a shelter In a motel or campground due to the lack of an alternative adequate accommodation In a car, park, abandoned building, or bus or train station Doubled up with other people due to loss of housing or economic hardship Your school-age children may qualify for certain rights and protections under the federal McKinney-Vento Act. Your eligible children have the right to: supports may be available. There also may be supports available for your preschool-age children. Local Liaison Carol Selby ext 2342 State Coordinator Mary Lebioda (MISD) If you need further assistance with your children s educational needs, contact the National Center for Homeless Education: * homeless@serve.org *

15 SCHOOL YEAR ALTERNATE BUS FORM ANCHOR BAY SCHOOLS TRANSPORTATION DEPARTMENT Office FAX Please fill out this form completely. Complete one form for each school your children attend. The Transportation Department will review requests and notify the parent of the approval within five (5) days. PLEASE PRINT DATE: SCHOOL: To Be Filled out by Parents: I hereby request permission and accept responsibility for my/our child(ren) listed below to be granted the following transportation change for pick up and/or drop off. NAME OF STUDENT(S) Grade School. Grade School NAME OF PARENT/GUARDIAN HOME ADDRESS ZIP Home Phone: Cell Phone: Work Phone CAREGIVERS NAME: PHONE # CAREGIVERS ADDRESS: PICK UP & DROP OFF PICK UP ONLY DROP OFF ONLY Parent Signature The Transportation Department will use the following criteria to base its decision to provide transportation from an alternate address: The alternate address is within the same school s attendance boundary The alternate stop is used be for all five (5) days a week The alternate stop is an existing stop on the bus run. The desired alternate bus run is not within 10% of load capacity The parents have been notified by the Transportation Office that the request has been approved. Approved requests will change your child s assignment to change to the alternate address. If your child should need to change back to the home stop, please contact the Transportation Department five (5) days prior to riding from the different stop. * * * * * * * * * * * * * * * * * * * * * * * * FOR OFFICE USE ONLY* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ROUTE: BUS: DRIVER: STOP LOCATION: APPROVED BY: DATE: EFFECTIVE: 1/24/14 REVISED FILE BUS DRIVER SCHOOL

16 August, 2015 Anchor Bay Schools Food & Nutrition Department Visit our website: Why is the price for lunch increasing? There is a required federal mandate that all school districts must comply with and it is called The Equity in School Lunch Pricing Provision Food & Nutrition Department proudly serving students everyday This USDA requirement states the full priced lunch cost must average to be equal or greater than $2.70 for the school year. Current lunch prices at Anchor Bay have an average of $2.44 for each full price meal. Therefore we are required to raise prices at a minimum of 10 cents. New Lunch Prices for 2015/16 School Year Elementary School Lunch = $2.40 Middle School and High School Lunch = $2.65 Reduced Lunch Cost =.40 cents Each student has an account that can be found online at SendMoneytoSchool.com Please note that there is a one time set up required (no fee for this). You may contact the Food & Nutrition Department at to obtain the student s 10 digit ID # to start. We ll be happy to help! HOW CAN I PREPAY FOR SCHOOL MEALS? 1. Send Cash to school with your student 2. Send Check payable to Anchor Bay Schools 3. Make an online payment at SendMoneyToSchool.com A $1.85 fee charged for each online deposit WE LOOK FORWARD TO SEEING AND SERVING YOUR STUDENT AT LUNCH!